Information Collection

Talk - Survey

IC 219174 under ICR 201306-0930-003 · OMB 0930-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Survey Talk - Survey	Form and Instruction
Survey Survey 2015_12_2_OMB Package_CSAP UAD TTHY Evaluation-Survey-AttachmentC.docx	Form and Instruction
Screener Screener 2015_12_2_OMB Package_CSAP UAD TTHY Evaluation-Survey-AttachmentA.docx	Form and Instruction
2015_12_3_OMB Package_CSAP UAD TTHY Evaluation-Survey.docx Supporting Statement	IC Document
TransLet-3doc.doc Transmittal Letter	IC Document
2015_12_2_OMB Package_CSAP UAD TTHY Evaluation-Survey-AttachmentB.docx Email Letters	IC Document

IC Title:

Talk - Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Survey	Survey	2015_12_2_OMB Package_CSAP UAD TTHY Evaluation-Survey-AttachmentC.docx		Yes	Yes	Fillable Printable
Form and Instruction	Screener	Screener	2015_12_2_OMB Package_CSAP UAD TTHY Evaluation-Survey-AttachmentA.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	2015_12_3_OMB Package_CSAP UAD TTHY Evaluation-Survey.docx	12/03/2015
Transmittal Letter	TransLet-3doc.doc	12/03/2015
Email Letters	2015_12_2_OMB Package_CSAP UAD TTHY Evaluation-Survey-AttachmentB.docx	12/03/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.